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Learning Curve to Lymph Node Resection in Minimally Invasive Esophagectomy for Cancer

Dhamija, Ankit MD*; Rosen, Joshua E. BASc; Dhamija, Anish BS; Gould Rothberg, Bonnie E. MD, PhD‡§; Kim, Anthony W. MD; Detterbeck, Frank C. MD; Boffa, Daniel J. MD

Innovations:Technology and Techniques in Cardiothoracic and Vascular Surgery: July/August 2014 - Volume 9 - Issue 4 - p 286–291
doi: 10.1097/IMI.0000000000000082
Original Articles

Objective Minimally invasive esophagectomy (MIE) is a safe alternative to open approaches, yet the impact of the minimally invasive approach on oncologic efficacy is unclear. The objectives of the current study were to compare lymph node yields and surgical margins during a single-surgeon series to examine the learning curve to oncologic aspects of MIE.

Methods A retrospective review of a prospectively maintained institutional database was performed. The sequential MIE experience for esophageal cancer was subcategorized into terciles (first 25 MIEs as early, next 24 as middle, and most recent 24 as later).

Results Seventy-three patients underwent MIE for cancer between 2008 and 2013. Complete resections (R0) were performed in 71 cases (93%), and there were no significant differences in the number of complete resections with negative margins during the MIE experience (P = 0.54). The number of lymph nodes harvested during MIE increased significantly with progressive experience, with a mean of 22, 29, and 28 nodes recovered in the early, middle, and late subgroups, respectively (P = 0.038). On multivariate analysis, only increasing surgeon experience (1.4-fold increase in nodal yield for the latter two thirds relative to the first third, P = 0.0011) and histology of high-grade dysplasia (0.54-fold decrease in nodal yield relative to adenocarcinoma or squamous cell carcinoma, P = 0.025) were significant predictors of lymph node yield.

Conclusions The ability to execute a complete lymphadenectomy during MIE is affected by surgeon experience and improves over time, plateauing after the first 25 cases.

From the *Department of Surgery, Morristown Memorial Hospital, Morristown, NJ USA; †Section of Thoracic Surgery, and ‡Division of Medical Oncology, Department of Internal Medicine, Yale University School of Medicine; and §Department of Epidemiology, Yale School of Public Health, New Haven, CT USA.

Accepted for publication December 31, 2013.

Ankit Dhamija, MD, and Joshua E. Rosen, BASc, contributed equally to this work.

Supported by the Yale University School of Medicine Medical Student Research Fellowship from the Yale University School of Medicine to Joshua E. Rosen, BASc; the US National Cancer Institute Grant #K08 CA151645, Bethesda, MD USA, to Bonnie E. Gould Rothberg, MD, PhD; and the US National Cancer Institute Grant #N44CO-2012-0049, Bethesda, MD USA, to Daniel J. Boffa, MD.

Disclosure: The authors declare no conflicts of interest.

Address correspondence and reprint requests to Daniel J. Boffa, MD, Division of Cardiothoracic Surgery, Yale University School of Medicine, 330 Cedar St, BB205, PO Box 208062, New Haven, CT 06520-8062 USA. E-mail:

©2014 by the International Society for Minimally Invasive Cardiothoracic Surgery